日本禁煙学会雑誌

第 6 巻第 5 号《原2011 年（平成 23 年）12 月 19 日

著》

Smoking status and the Kano Test forSocial Nicotine Dependence（KTSND）
in employees of a regional cancer center in Japan
Kenji Amagai 1, 2, 11 、Yosikazu Nakamura 2 、Chiharu Yoshii 3, 11 、Masato Kano 4, 11
Koji Inagaki 5, 11 、Masako Kitada 6, 11 、Tetstuya Otani 7, 11 、Shohei Harada 7, 11
Narito Kurioka 8, 11 、Masahiro Tanaka 9, 11 、Hideo Tanaka 10
1．

Department of Gastroenterology, Ibaraki Prefectural Central Hospital
Department of Public Health, Jichi Medical University
3．
Department of Respiratory Medicine, University of Occupational and Environmental Health Japan
4．
Shinnakagawa Hospital
5．
Department of Dental Hygiene, Aichi-Gakuin Junior College
6．
Faculty of Business administration, Sapporo Gakuin University
7．
National Center for Child Health and Development
8．
Johoku Hospital
9．
Department of Cancer Control and Statistics Osaka Medical Center for Cancer andCardiovascular Diseases
10．
Division of Epidemiology and Prevention, Aichi Cancer Center Research Institute11．
Research Group on Smoke-Free Psychology
2．

Objectives
We investigated the prevalence of smoking and attitudes concerning smoking among employees of a cancer hospitalusing the Kano Test for Social Nicotine Dependence (KTSND).
Methods
A self-administered questionnaire, including the KTSND as well as questions regarding smoking status, occupationand demographics were collected from 611 employees of a regional cancer center.
Results
The smoking rates were as follows: medical doctors, 5.4% (male 5.8%, female 0.0%); nurses, 17.4% (male 50.0%,
female 15.5%); other medical workers, 3.9% (male 7.7%, female 0.0%); clerical or site maintenance workers 21.9% (male39.7%, female 12.4%). The KTSND scores (mean ± standard deviation) of 14.7 ± 4.4 for smokers were significantly
higher than those of 12.2 ± 4.7 for past smokers, and 11.0 ± 5.9 for never-smokers. Although the KTSND scores were notdifferent in each occupational category among never smokers, those for clerical or site workers (17.2 ± 5.4) weresignificantly higher than those for medical doctors (12.3 ± 6.2) or nurses (13.7 ± 5.0) among past or current smokers.
Current smokers but also never and past smokers gave a strongly positive response to permission of smoking whereashtrays are available.
Conclusions
The prevalence of smoking in the staff in a regional cancer center was not lower than expected. A significant
difference was observed in KTSND scores according to smoking status, and the KTSND scores differed according to
occupational category in the hospital. It is suggested that it is necessary to remove ashtrays and abolish smoking areas
to discourage smoking in hospitals.
Key words
Kano Test for Social Nicotine Dependence (KTSND), smoking, nicotine dependence, hospital workers
Address for correspondence

Kenji Amagai, Department of Gastroenterology, Ibaraki Prefectural Central Hospital,
6528 Koibuchi, Kasama, Ibaraki, 309-1793, Japan
TEL:+81-296-77-1121 FAX:+81-296-77-2886
e-mail:
受付日 2011 年 1 月 4 日 採用日 2011 年 10 月 14 日

Smoking status and KTSND of employees in a cancer center71

日本禁煙学会雑誌

第 6 巻第 5 号

2011 年（平成 23 年）12 月 19 日

norms regarding smoking. It can be quantified by a
10-item questionnaire, the Kano Test for Social
Nicotine Dependence（KTSND）. The KTSND has
been widely sampled to examine its usefulness.
In the current survey, the KTSND was administered as a portion of a questionnaire designed toevaluate the attitudes of staff regarding tobacco use,with a view to formulation of adequate anti-tobacco
use measures in the Ibaraki Prefectural Central
Hospital and Cancer Center.

INTRODUCTION
Smoking is the main risk factor for lung cancer,
and it is known that continuation of tobacco use
increases the risk of cancer and of other diseases.
The Japanese Cancer Association 1）, the JapaneseRespiratory Society 2）, the Japanese Circulation
Society 3）, and the Japanese Nursing Association 4）
have issued non-smoking policy statements, andrequest that their members promote various activities to increase the rate of cessation of smoking. It is
desirable that anti-smoking measures be planned
and introduced systematically rather than dependingon the efforts of individuals.
The Japanese Association of Clinical Cancer
Centers（JACC）was established in 1973 for the
purpose of contributing to improvements inprevention, diagnosis, and the treatment of cancer 5）.
The secretariat of the JACC devised a tobacco
control plan to consolidate their position as a rolemodel for other hospitals in 2006 6）. The planestablished that each hospital should keep thesmoking rate in all health professionals employed atless than 10 ％ . Among the staff members working
at each hospital, it is desirable that physicians,
nurses, pharmacists, medical social workers, andphysical therapists, who are in the position ofadvising patients about their health, medical care,and medical treatment, be nonsmokers and act asrole models at an individual level. To achieve thisaim, a staff questionnaire about tobacco use wasadministered in 2008 as a baseline investigation at
the Ibaraki Prefectural Central Hospital and Cancer
Center, which is a member of the JACC.
“Social nicotine dependence” is a concept describing a psychological and psychosocial state
associated with smoking. That dependence wasdefined by Kano 7, 8） as cognitive distortions related
to smoking caused by smokersʼ attempts to undervalue the harm of smoking or overvalue thefavorable effects of smoking, and to justify smoking
as acceptable cultural and social behavior. This
psychological nicotine dependence of smokers often
affects the attitude of nonsmokers and children
around them, consequently influencing the social

METHODS
Study Subjects

The study subjects were employees at the Ibaraki
Prefectural Central Hospital and Regional Cancer
Center. The questionnaire was distributed to workers
in each section of the hospital. The study protocol
was approved by the Review Board of the hospital.
Questionnaire（Appendix 1）

The self-administered questionnaire was distributed in June 2008, and was returned by July 2008.
It included questions on demographic characteristics, such as gender and age, working years as aprofessional, smoking status, and exposure tosecond-hand smoking, and also included theKTSND. For medical doctors, nurses, and pharmacists, there was also a question regarding theirpractice in advising patients to quit smoking.
KTSND（Appendix 2）

The KTSND, version 2.1, consisted of 10 questions with the following instructions for the
subjects: ʻʻWe will ask you about your perception ofsmoking. Please circle the reply that best reflects
your opinion.ʼʼ Each question had a choice of four
responses:
ʻʻDefinitely Yes,ʼʼ ʻʻProbably Yes,ʼʼ ʻʻProbably No,ʼʼand ʻʻDefinitely No.ʼʼ with scores of 3, 2, 1 and 0,
respectively, except for Question 1, which wasscored in the reverse order. Individual item scores
were added to give a total KTSND score that ranged
from 0 to 30, higher scores indicating greater social
dependence on nicotine.

Smoking status and KTSND
タイトルof employees in a cancer center72

日本禁煙学会雑誌

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2011 年（平成 23 年）12 月 19 日

PASW Statistics version 18.0（SPSS Inc.）was used
for all statistical analyses. The statistical level ofsignificance was set at 0.05.

Statistical Analysis

KTSND scores were compared among threesmoking status groups, i.e., never-smokers, pastsmokers, and current smokers. In addition, comparisons were made among the type of jobs and theawareness of second-hand smoking. The MannWhitney U test was used for comparison between
two groups, or the Kruskal-Wallis test for comparison among three or more groups. Logistic regression analyses were used to evaluate associations
between the KTSND scores and gender, age, type ofjob, years working as a professional, smoking
status, or awareness of second-hand smoking. Odds
ratios（ORs）and their 95 ％ confidence intervals（CIs）of high KTSND scores（≥ 10）were calculated
for all types of jobs. We set the cutoff value between
normal and high KTSND sores as 10, based on the
result of a survey in a sample of attendees of atobacco control meeting who were free from social
nicotine dependence 9）.
The multivariate model was adjusted for theabove-mentioned variables with a stepwise elimination procedure. The statistical software package

RESULTS
Background characteristics of subjects

The questionnaire was distributed to a total of
775 employees, and questionnaires were returned
from 617 respondents（79.6 ％）. A dataset including
the type of job was available for 611 respondents（78.8 ％）
（Table 1）. The majority of respondents
were female（72.9 ％）. The highest proportion ofsubjects were aged 40–49（28.9 ％）, followed bythose aged 30 – 39（28.5 ％）, 20 – 29（20.7 ％）,50 – 59 （ 17.6 ％） a n d 60 – 69 （ 4.3 ％）. T h e
respondents consisted of 93 current smokers（16.0 ％）, 95 past smokers（16.4 ％）, and 393 neversmokers（67.6 ％）.
Smoking rates

Smoking rates were found to vary according togender, with 22.0 ％ of males and 12.9 ％ females
being smokers. According to age group, theTable 1. Background characteristicsof the subjects
Table 1. Background characteristics of the subjects
Medical doctors

NursesOther medical workers

Clerical or on-site
workers

All subjects
98Smoking rate and distribution334
87 and age group
256
Table 2.
according to gender
Returned (%)
56 (57.1)
258 (77.2)
78 (89.7)
225 (87.9)
Clericalor on-site
Medical doctors
NursesOther medical workers
workers
Replied (%)
56 (57.1)
252 (75.4)
78 (89.7)
225(87.9)
GenderCurrent smokers (%)
3/56 (5.4)
42/242 (17.4)
3/77 (3.9)
45/206 (21.9)
52(92.9)
10 (4.0)
39(50.0)
63 (28.1)
Males (%)
3/52
(5.8)
5/10
(50.0)
3/39
(7.7)
25/63
(39.7)
4 (7.1)238 (96.0)
39(50.0)
161 (71.9)
Females (%)
0/4
(0.0)
37/238(15.5)
0/39(0.0)
20/161(12.4)
Missing responses
00
44
00
11
Age
Females)Age(year;groupMales,(year, males)


13
(13,
0)
453/5
(5,(60)40)
26(10,(10.0)
16)
41
32)
20–29
2/13
(15.4)
1 /10
5/9(9,(55.6)


12
(10,
2)
93
90)
14 (6,
53
(14,
39)
30–39
1/10
(10.0)
1/3(3,(33.3)
0/68)
6/14(42.9)

19 (19,
68
66)
23
(15,
8)
64
(20,
44)
40–49
0/190)
1/2(2,(50.0)
1/15
(6.7)
9/20
(45.0)


9 (8,
39 (0,- 39)
14
7)
43
34)
50–59
0/81)
1/7(7,(14.3)
1/9(9,(11.1)


3 (2,
2 (0,- 2)
1 (1,0 0)
20
(10,
10)
60–69
0/21)
3/10
(30.0)
Missingresponses
responses
05041
MissingYears
workingin thehospital (males, females)
Age group(year,
females)
220–29yr or less27 (25,
38(6,(17.5)
32)
30 (11,
115(28,(6.2)
87)
- 2)
7/40
0/1619)2/32
3–5
yr
15 (14,35 (0,(21.1)
35)
17 (7,
57
(20,
37)
30–39
0/2 1)
19/90
0/810)
8/39(20.5)
6–10
yr
7 (7,- 0)
41(4,(12.1)
37)
6 (4,
20
(3,(15.9)
17)
40–49
8/66
0/82)
7/44
11
yr +
7 (6,
133
(0,(7.7)
133)
24 (17,283/34(12,(8.8)
16)
50–59
0/11)
3/39
0/7 7)
Missing responses
0
1
00
60–69
0/1
0/2
0/10
Smoking
Missing responses
Never (%)
37 (66.1)
168 (69.4)
54 (70.1)
134 (65.0)
Past (%)
16 (28.6)
32 (13.2)
20 (26.0)
27 (13.1)
Current (%)
3 (5.4)42 (17.4)
3 (3.9)45 (21.9)
Missing responses
0
10
1
19
Second-hand smoking
Aware (%)
44 (78.6)
190 (77.2)
64 (85.3)
162 (79.0)
None (%)
12 (21.4)
56 (22.8)
11 (16.7)
43 (21.0)
Missing responses
0
6
3
20

Smoking status and KTSND
タイトルof employees in a cancer center

73

Total
775
617 (79.6)
Total
611 (78.8)
93/581 (16.0)
164 (27.1)
36/164(22.0)
442 (72.9)
57/442(12.9)
55
125
(37,
88)
11/37
(29.7)
172
(33,
139)
8/33
(24.2)
174(56,(19.6)
118)
11/56
106
(24,
81)
2/24
(8.3)
26
(13,
13)
3/12
(25.0)
91
210
(70,
140)
9/88
(10.2)
124(41,(19.4)
83)
27/13974 (18,(12.7)
56)
15/118
1926/81(35,(7.4)
157)
1
0/13
393 (67.6)
95 (16.4)
93 (16.0)30
460 (79.0)
122 (21.0)29

日本禁煙学会雑誌

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2011 年（平成 23 年）12 月 19 日

smoking rates were highest（29.7 ％）for males intheir 20's, followed by those in their 30's, 40's, and60's. For females, the smoking rate was 19.4 ％ for
those in their 30's, followed by those in their 40's,
20's, and 50's. The smoking rate also varied
according to the type of job; it was highest（21.9 ％）for clerical or site maintenance workers, followedby nurses（17.4 ％）, medical doctors（5.4 ％）, andother medical workers（3.9 ％）（Table 2）.

KTSND scores by smoking status

The KTSND score of current smokers（16.5 ± 5.3,
mean ± standard deviation）was significantly higher
than those of past smokers（14.0 ± 5.5）and neversmokers（11.3 ± 5.8）
（P < 0.001）. In addition, thescore of past smokers was significantly higher thanthose of never-smokers（P < 0.001）（Table 3）.
According to the type of job, the score of smokers

Table 2. Smoking rate and distribution
according to gender and age group
Table 2. Smoking rate and distribution according to gender and age group
Current smokers (%)
Males (%)
Females (%)
Missing responses
Age group (year, males)
20–29
30–39
40–49
50–59
60–69
Missing responses
Age group (year, females)
20–29
30–39
40–49
50–59
60–69
Missing responses

Medical doctors

NursesOther medical workers

3/56 (5.4)
3/52 (5.8)
0/4 (0.0)042/242 (17.4)
5/10 (50.0)
37/238 (15.5)
4

3/77 (3.9)
3/39 (7.7)
0/39 (0.0)
02/13 (15.4)
1/10 (10.0)
0/19
0/8
0/2
-

3/5 (60)
1/3 (33.3)
1/2 (50.0)
-

0/2
0/1
0/1
-

7/40 (17.5)
19/90 (21.1)
8/66 (12.1)
3/39 (7.7)
0/2-

Clerical or on-site
workers

Total

45/206 (21.9)
25/63 (39.7)
20/161 (12.4)
1

93/581 (16.0)
36/164 (22.0)
57/442 (12.9)
5

1 /10 (10.0)
0/6
1/15 (6.7)
1/7 (14.3)
0-

5/9 (55.6)
6/14 (42.9)
9/20 (45.0)
1/9 (11.1)
3/10 (30.0)
1

11/37 (29.7)
8/33 (24.2)
11/56 (19.6)
2/24 (8.3)
3/12 (25.0)
1

0/16
0/8
0/8
0/7
-

2/32 (6.2)
8/39 (20.5)
7/44 (15.9)
3/34 (8.8)
0/10-

9/88 (10.2)
27/139 (19.4)
15/118 (12.7)
6/81 (7.4)
0/13-

Table 3. The Kano TestTable
for3.Social
Dependence（KTSNDscoresthe subjects
The KanoNicotine
Test for Social
Nicotine Dependence(KTSND)）scoresof the ofsubjects

The KTSND scores of all subjects, mean ± SD
Never-smokers
Past smokers
Current smokers
Comparison according to gender
Males
FemalesAmong the never-smokers
Males in never-smokers
Females in never-smokers
Comparison according to exposure to secondhand smoking

Medical doctors

NursesOther medical
workers

Clerical or on-site
workersTotal(n = 56)
12.6 ± 6.4
12.8 ± 6.5
12.1 ± 6.8f
13.3 ± 1.5f

(n = 246)
12.0 ± 5.9
11.1 ± 6.0a
12.4 ± 5.2a, f
15.0 ± 4.6a, f(n = 77)
12.6 ± 6.1
11.2 ± 6.0b15.4 ± 4.6b, f
21.0 ± 6.0b, f(n = 221)13.1 ± 6.0
11.3 ± 5.3a
16.0 ± 4.8a, f
17.8 ± 5.6a, f(n = 600)
12.6 ± 6.0
11.3 ± 5.8a
14.0 ± 5.5a
16.5 ± 5.3a12.6 ± 6.5g
13.3 ± 5.1

17.3 ± 6.2c, g
11.7 ± 5.7c

13.9 ± 6.7g
11.4 ± 5.3

16.2 ± 6.5d, g
12.2 ± 5.4d

14.5 ± 6.7d
11.8 ± 5.6d

12.8 ± 6.8
13.3 ± 5.1

17.0 ± 11.3
11.0 ± 5.9

11.6 ± 7.3
11.0 ± 5.3

12.6 ± 6.4
11.0 ± 5.0

12.6 ± 6.9e
11.0 ± 5.5e

12.7 ± 5.6 (43)13.5 ± 6.0 (158)12.2 ± 6.4 (120)12.7 ± 5.9 (452)12.0 ± 5.8 (31)11.1 ± 4.9 (94)11.8 ± 6.6 (88)11.2 ± 5.5 (292)No (number of respondents)
13.9 ± 6.8 (12)11.2 ± 6.2 (54)13.0 ± 9.5 (11)
Yes (number of respondents)
12.3 ± 6.3 (44)12.2 ± 5.8 (187)12.6 ± 5.5 (63)Among the never-smokers
13.3 ± 6.7 (7)11.3 ± 6.5 (41)11.9 ± 9.8 (9)No (number of respondents)
Yes (number of respondents)
12.7 ± 6.6 (30)11.0 ± 5.8 (124)
11.2 ± 5.1 (44)a
The KTSND scores were different according to smoking status (Kruskal-Wallis test, P < 0.001).
b
The KTSND scores were different according to smoking status (Kruskal-Wallis test, P < 0.01).
c
The KTSND scores of females were lower than those of males (Mann-Whitney U test, P < 0.01).
d
The KTSND scores of females were lower than those of males (Mann-Whitney U test, P < 0.001).
e
The KTSND scores of females were lower than those of males (Mann-Whitney U test, P < 0.05).
f
The KTSND scores were different according to the type of job (Kruskal-Wallis test, P < 0.05).
g
The KTSND scores were different according to the type of job (Kruskal-Wallis test, P < 0.01).
SD: Standard deviation

Smoking status and KTSND
タイトルof employees in a cancer center74

日本禁煙学会雑誌

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was significantly higher than those of past smokers
and never-smokers in the groups of nurses, othermedical workers, and clerical or site workers, butthere were no significant differences in those of
medical doctors. Comparison according to gender
showed the score of females（11.8 ± 5.6）to be lower
than that of males（14.5 ± 6.7）
（P < 0.001）. The
significant difference in scores between males andfemales was seen in the groups of nurses andclerical or site workers. Among the never-smokers,
there were significant differences in scores between
males and females, but no significant difference
was found among any types of job. The scores for
those who suffered from second-hand smoking（12.7 ± 5.9）were not different from those who were
unaware of the possible damage from second-handsmoking（12.2 ± 6.4）. This tendency was also seenin the group of never-smokers.

2011 年（平成 23 年）12 月 19 日

Scores for each question
Table 4 shows significant differences among

never-smokers, past smokers, and current smokers
except for Q1（Smoking itself is a disease）. In
smokers, Q10（People can smoke at places whereashtrays are available）showed the highest score（2.49 ± 0.80）, followed by Q7（Tobacco has effects
to relieve stress）（2.11 ± 0.77）and Q3（Tobacco is
one of lifeʼ s pleasures）. Even never-smokers andpast smokers tended to answer positively to Q10（2.08 ± 1.10 and 2.31 ± 0.5, respectively）.
KTSND scores and scores for each question forpast or current smokers

The KTSND scores show significant differencesamong the type of jobs in past and current smokers
but not in never-smokers（Table 3）. Table 5
presents the significant differences among occupational category in the KTSND scores for Q5

Table 4. Scores for each question
inforalleachsubjects
to smoking
Table 4. Scoresquestion inaccording
all subjects according
to smokingstatus
statusQ 1: Smoking itself is a disease
Q 2: Smoking is a part of culture
Q 3: Tobacco is one of life’s pleasures
Q 4: Smokers’ lifestyles may be respected
Q 5: Smoking sometimes enriches people’s lives
Q 6: Tobacco has positive physical or mental effects
Q 7: Tobacco has effects to relieve stressQ 8: Tobacco enhances the function of smokers’ brains
Q 9: Doctors exaggerate the ill effects of smoking
Q 10: People can smoke at places where ashtrays are available

Never-smokers(n = 384)
Mean ± SD
1.27 ± 1.05
0.92 ± 1.01
1.73 ± 1.17
1.08 ± 0.97
1.05 ± 0.98
0.76 ± 0.92
1.35 ± 0.99
0.57 ± 0.73
0.53 ± 0.75
2.08 ± 1.10

Past smokers(n = 94)
Mean ± SD
1.36 ± 1.03
1.39 ± 0.90
1.99 ± 1.02
1.45 ± 0.89
1.31 ± 0.96
1.07 ± 0.92
1.63 ± 0.86
0.81 ± 0.85
0.65 ± 0.79
2.31 ± 0.95

Current smokers
P-value(n = 88)
Mean ± SD(Kruskal-Wallis test)
1.42 ± 1.03
1.36 ± 1.06
2.07 ± 1.00
1.93 ± 0.77
1.45 ± 0.93
1.36 ± 0.94
2.11 ± 0.77
1.00 ± 0.87
1.23 ± 1.00
2.49 ± 0.80

0.413
0.000
0.026
0.000
0.000
0.000
0.000
0.000
0.000
0.003

Table 5. The Kano Test for Social Nicotine Dependence（ KTSND ）scores and scores of eachquestion ofTable
past
or Kanocurrent
5. TheTest forsmokers
Social Nicotine Dependence (KTSND) scores and scores of each question of past or current smokers

The KTSND scores

Q 1: Smoking itself is a disease
Q 2: Smoking is a part of culture
Q 3: Tobacco is one of life’s pleasures
Q 4: Smokers’ lifestyles may be respected
Q 5: Smoking sometimes enriches people’s lives
Q 6: Tobacco has positive physical or mental effects
Q 7: Tobacco has effects to relieve stressQ 8: Tobacco enhances the function of smokers’ brains
Q 9: Doctors exaggerate the ill effects of smoking
Q 10: People can smoke at places where ashtrays are available

Medical doctors

Nurses(n = 19)
Mean ± SD(n = 71)
Mean ± SD

12.26 ± 6.21
1.05 ± 0.97
1.26 ± 0.99
1.95 ± 1.27
1.47 ± 1.07
1.11 ± 1.10
0.84 ± 0.90
1.37 ± 0.96
0.58 ± 0.77
0.53 ± 0.84
2.11 ± 1.10

13.70 ± 5.03
1.31 ± 1.01
1.23 ± 0.94
1.86 ± 1.12
1.58 ± 0.94
1.21 ± 0.94
1.10 ± 0.88
1.75 ± 0.81
0.68 ± 0.73
0.82 ± 0.87
2.27 ± 0.97

Other medical Clerical or on-site
workers
workers(n = 21)
Mean ± SD

15.67 ± 4.55
1.24 ± 0.94
1.81 ± 0.81
2.29 ± 0.72
1.52 ± 0.75
1.76 ± 0.70
1.29 ± 1.15
1.76 ± 1.04
0.90 ± 0.94
0.67 ± 0.73
2.43 ± 0.75

Smoking status and KTSND
タイトルof employees in a cancer center

75(n = 71)
Mean ± SD

17.15 ± 5.40
1.61 ± 1.05
1.44 ± 1.02
2.14 ± 0.87
1.89 ± 0.73
1.51 ± 0.94
1.41 ± 0.90
2.14 ± 0.70
1.21 ± 0.89
1.23 ± 1.02
2.59 ± 0.73

P-value(Kruskal-Wallis test)
0.001
0.109
0.096
0.499
0.105
0.028
0.081
0.001
0.001
0.006
0.107

日本禁煙学会雑誌

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2011 年（平成 23 年）12 月 19 日

（Smoking sometimes enriches peopleʼ s lives）, Q7（ Tobacco has effects to relieve stress ）, Q 8（Tobacco enhances the function of smokersʼ brains）

and Q9.（ Doctors exaggerate the ill effects ofsmoking）.

current smoker. In the multivariate model, the OR
values（95 ％ CI）of the high KTSND scores for the
past and current smoker groups were 2.72（1.54–
4.82）and 6.11（ 2.85 –13.07）, and significant
differences were found for the 40–49 yr age group,with an OR of 0.44（0.25– 0.77）.

High KTSND scores and related factors
Table 6 presents the association of variables withDISCUSSION
There have been many previous studies into thesmoking status of medical institution staff, but we
conducted this survey, not only on medical professionals but also on non-medical staff such as

high KTSND scores versus normal KTSND scores.
A significant association was found in the univariate models between high KTSND scores and malegender, the 40–49 yr age group, past smoker or

Tableratiosofofhigh
highKano
Kano
Test
SocialNicotine
Dependence（KTSNDscoresnormal
versusTable6.6.Odds
Odds ratios
Test
for forSocialNicotine
Dependence(KTSND)scores）versus
normal KTSND scores for variables
inthehospital
workers
KTSND scores for variables in the hospital workers
Multivariate¶
Variables
Category
Univariate
OR (95% CI)
OR (95% CI)
Gender
1.70 (1.12–2.59)*
Males
Females1 (reference)Age< 30
1 (reference)
1 (reference)
30–39
0.75 (0.44–1.28)
0.62 (0.35–1.10)
0.51 (0.30–0.86)*
0.44 (0.25–0.77)*
40–49
50+
0.62 (0.35–1.81)
0.63 (0.34–1.17)
Type of job
Medical doctors
1 (reference)
Nurses1.04 (0.56–1.93)
Other medical workers
0.88 (0.42–1.82)
Clerical or on-site workers
1.26 (0.67–2.38)
Working years as a professional
2 yr or less1 (reference)
3–5 yr
0.71 (0.44–1.17)
6–10 yr0.56 (0.31–1.00)
11 yr +
0.69 (0.45–1.07)
Smoking status
Never-smoker
1 (reference)
1 (reference)***
2.77 (1.58–4.88)
2.72 (1.54–4.82)**
Past smoker***
6.28 (2.92–13.35)
6.11 (2.85–13.07)***
Current smoker
Suffered from second-hand smoking
Yes1.32 (0.86–2.04)
No
1 (reference)High KTSND scores defined as a score of 10 or more and normal KTSND scores defined lesas a score lessthan 10.
*
P < 0.05, ** P < 0.01, *** P < 0.001

Adjusted for gender, age group, type of job, working years as a professional, smoking status, exposure tosecond-hand smoking in a multivariate model with stepwise elimination procedure at the P = 0.05
significance level for entry into the model. OR: Odds ratio, CI: confidence interval¶

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日本禁煙学会雑誌

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2011 年（平成 23 年）12 月 19 日

clerical or on-site workers. When nonsmoking
promotion is carried out at any institution, thecooperation of all staff members is necessary,
regardless of their employment capacity, as all are
expected to be knowledgeable regarding this issue
and to promote awareness by serving as individualrole models. In the present study, the smoking rates
for all staff were 22.0 ％ in males and 12.9 ％ infemales, and the rates for clerical or site workers
were 39.7 ％ in males and 12.4 ％ in females. The
smoking rate in non-medical workers was similar tothat found in the national health and nutrition
examination survey in 2007, 39.4 ％ in males and11.0 ％ in females 10）. The smoking rates of medical
doctors in this study were 5.4 ％ in males and 0.0 ％in women, and were lower than those reported formembers of the Japan Medical Association in 2008
（15.0 ％ in males and 4.6 ％ in females）11）. The
response rate from medical doctors was particularly
low, and it is very likely that answers from smokers
were not obtained, meaning that the real smoking
rate would be somewhat higher. The smoking rates
of nurses in the current study were 50.0 ％ in males
and 15.5 ％ in females, which was similar to the54.2 ％ in males and 18.5 ％ in females reported for
the Japan Nursing Association in 2006 12）. The
employee smoking rates were not found to beparticularly low in this institution, indicating that
support for cessation of smoking for staff isnecessary.
We conducted a questionnaire survey including
the KTSND to evaluate attitudes toward smoking in
the hospital staff, and for the purpose of clarifying
disincentives to anti-smoking promotion. The
ranges of mean KTSND scores according tosmoking status have been reported as 10–13 fornever-smokers, 12–16 for past smokers, and 16–18
for current smokers 7, 13~18）, while the corresponding
KTSND scores in our study were 11.3 for neversmokers, 14.0 for past smokers, and 16.5 for current
smokers. These scores are similar and the scores for
hospital workers were not particularly low.
In our survey, smokers gave strongly positive
answers for Q3, Q7 and Q10, quite similar to thatof a previous study in employees of pharmaceuticalcompanies 7）. On the other hand, not only current
smokers but also never and past smokers gave astrongly positive response for Q10. Based on theseresults, it is necessary to remove ashtrays andabolish smoking areas to make hospitals or otherpublic domains smoke-free.
In addition, in past and current smokers, there
were significant differences among occupational
category in the KTSND scores, Q5, Q7, Q8, and Q
9. Past and current smokers who were clerical orsite workers particularly overvalued the favorable
effects of smoking compared with those who were
medical doctors or nurses. In this survey, theprevalence of smoking male clerical or site workers
is high as in the general population in Japan.
Hasegawa et al. described differences in smoking
behavior, attitude and knowledge of smoking
effects among healthcare professionals 19）. They
reported that the smoking rate of clerical workers
was higher and they had less knowledge and morepositive feelings toward smoking than medical
doctors or nurses. To promote cessation of smoking
in these employees, we should supply information
not only on the harm resulting from smoking but
also on misunderstandings concerning the favorable
effects of smoking. On the other hand, smoking
medical doctors and nurses continue to smoke
although they do not recognize the favorable effectsof smoking. The relationship between occupational
category and KTSND scores were not suggested inprevious studies in hospital workers, and thepossibility of a new application of KTSND issuggested for promoting smoke-free hospitals.
Yoshii et al. proposed that KTSND scores lessthan 10 represent a desirable psychological state
free from the influence of smoking 9）. A score ofmore than 10 points is regarded as a high KTSND
score, and logistic regression analysis indicated asignificant correlation between high KTSND scores
and age and smoking status, and this tendency was
similar to that observed in a previous study 20）. In
younger generations, social nicotine dependencies
may be affected by promotions by tobacco com-

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日本禁煙学会雑誌

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panies even in healthcare professionals without
appropriate education about smoking in medical
and nursing schools in Japan. We plan to regularly
conduct surveys regarding smoking rates in the
future. Although achieving a decrease in smoking
prevalence requires many years, we expect thatKTSND scores will decrease earlier than smoking
prevalence in hospital workers.
Regarding the limitations of the study, the survey
was conducted in only one medical institution. A
previous study reported that KTSND scores weredifferent in hospitals with different employeesmoking rates 13）. Another study showed that the
KTSND reflected medical doctorsʼ attitudes tosmoking cessation in patients with lung cancer orthe level of institutional tobacco control 20）. Therefore, we plan to conduct these surveys in several
other regional cancer centers and longitudinally toclarify factors influencing smoking status and theKTSND scores of hospital workers. Anotherlimitation in this survey was that smoking status
was defined by self-returned answers. Biochemicalassessments of smoking by-products such as
cotinine or carbon monoxide are often made tovalidate self-reports of smoking, but a review andmeta-analysis showed that those measurements are
obtrusive and self-reports of smoking are accurate
in most studies 21）. Another limitation is thequestion naire did not include items on sociodemographic factors, lifestyle, mental health andwork stress. Recently, in Japanese civil servants,
one study reported a relationship between smoking
behavior and socio-demographic, lifestyle, andmental health characteristics 22）. Arima et al 23）.
reported the status of smoking cessation supported
by nurses in general hospitals. They surveyed sociodemographics, smoking status, work-related stress,
experience of learning how to support smoking
cessation, knowledge about smoking hazards, andmethods of assistance for quitting smoking.
Consequently, they concluded that it was necessary
to broaden training programs to increase selfefficacy. In our study, the questionnaire contained
recognition of the Japanese Nursing Associationʼ s

2011 年（平成 23 年）12 月 19 日

anti-smoking action plan and the practice ofadvising patients to quit smoking, but other detailed
factors were absent. Further study is therefore
needed to determine the causal relationship between
smoking behavior and socio-demographic factors,
lifestyle, mental health and status of smoking
cessation in detail.

CONCLUSIONSThis study, investigating smoking status andattitude to tobacco use in the staff of a regional
cancer center, found that the smoking rate wasrather high. A significant difference was seen in
KTSND scores according to smoking status, and theKTSND scores differed according on the occupational category of the hospital workers. The results
suggest that it is necessary to remove ashtrays andabolish smoking areas to discourage smoking in
hospitals.
A part of this report was presented at the 68th
Japanese Society of Public Health general meeting（October 2009, Nara）.
References
1） Non-Smoking Declaration of the Japanese Cancer
Association. Retrieved January 2, 2011, fromhttp://www.jca.gr.jp/researcher/smoking/declara
tion.html
2） Declaration of Opposition to Smoking from theJapanese Respiratory Society. Retrieved January
2, 2011, from http://www.jrs.or.jp/home/modules/
citizen/index.php?content_id=79
3） Fujiwara, H: Anti-Smoking Declaration. A Message From The Japanese Circulation Society.
Retrieved January 2, 2011, from http://www.jsta
ge.jst.go.jp/article/circj/67/1/1/_pdf
4） JNA Anti-Smoking Declaration for Nursing
Professionals. Retrieved January 2, 2011, fromhttp://www.nurse.or.jp/home/publication/pdf/
hyoushi.pdf
5） Japanese Association of Clinical Cancer Centers.
Retrieved January 2, 2011, from http://www.zen
gankyo.ncc.go.jp/
6） Tanaka H, Miyamatsu A, Amagai K, et al.
Tobacco control planning of the Japanese Association of Clinical Cancer Centers. Jpn Med J. 2007;
4352: 75-9.

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タイトルof employees in a cancer center78

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2011 年（平成 23 年）12 月 19 日

7） Yoshii C, Kano M, Isomura T, et al. An innovative
questionnaire examining psychological nicotine
dependence, “The Kano Test for Social Nicotine
Dependence（ KTSND ）.” J UOEH. 2006; 28:
45-55.
8） Kanagawa Physicians Association. Tobacco is not
one of lifeʼ s pleasures. In: Kanagawa Physicians
Association, ed. Basic knowledge for Antismoking Medical Care. Tokyo: Chuwa Printing;
2006: 3-5.
9） Yoshii C, Kurioka N, Kano M, et al. The Kano
Test for Social Nicotine Dependence（KTSND）in
samples from the attendants of “Miyako Tobacco
Control Meeting” . Jpn J Tob Control. 2008; 3:
26-30.
10）Ministry of Health, Labor, and Welfare. The
National Health and Nutrition Examination
Survey in 2007. Retrieved January 2, 2011, fromhttp://www.mhlw.go.jp/houdou/2008/12/h1225-5.
html11）Kaneita Y, Ohida T, Uchida T. Prevalence andcorrelates of smoking among Japanese physicians:
Result from the 2008 Survey on the Smoking
Activities of Japan Medical Association Members.
Nippon Ishikai Zasshi 2009; 138: 770-712）Smoking status of the nursing professionals in
2006. Retrieved January 2, 2011, from http://
www.nurse.or.jp/home/publication/pdf/2007/
tabakohokoku.pdf
13）Yoshii C, Kano M, Inagaki K, et al. The Kano
Test for Social Nicotine Dependence（KTSND）in
samples f rom three hospital employees inFukuoka prefecture. Jpn J Tob Control. 2007; 2:
6-9.
14）Kurioka N, Inagaki K, Yoshii C, et al. Investigation of the perception of female students
towards tobacco smoking with The Kano Test forSocial Nicotine Dependence（KTSND）in 2006.
Jpn J Tob Control. 2007; 2: 62-7.

15）Inagaki K, Hayashi J, Ting CC, et al. Dental
undergraduatesʼ smoking status and social nicotine
dependence in Japan and Taiwan - comparison
between two dental schools. Jpn J Tob Control.
2008; 3: 81-5.
16）Otani T, Yoshii C, Kano M, et al. Validity andreliability of Kano Test for Social Nicotine
Dependence. Ann Epidemiol. 2009; 19: 815-22.
17）Sezai I, Inagaki K, Koide T, et al. Associations
between smoking status, social nicotine dependence and daily hassles among middle-aged andelderly. Jpn J Tob Control. 2009; 4: 91-9.
18）Inagaki K, Mukai M, Bessho M, et al. Smoking
status and social nicotine dependence among
workers and teachers in the Kusumoto campus ofAichi-Gakuin University. The Aichi-Gakuin
Journal of Dental Science. 2009; 47: 281-92
19）Hasegawa T, Ishizaki T, Uehara Y, et al. Analysis
of smoking behavior , knowledge, and attitude
among health care professionals. J Interdiscipl
Res. 2005; 6; 17-25.
20）Yoshii C, Inoue N, Yatera K, et al. An evaluationof social nicotine dependence of participants at
the Annual Meeting of the Japanese Lung Cancer
Society Using the Kano Test for Social Nicotine
Dependence. JJLC. 2010; 50; 272-9.
21）Patrick DL, Cheadle A, Thompson DC, et al. The
validity of self-reported smoking: a review andmeta-analysis. Am J Public Health 1994; 84: 108693
22）Hu L, Sekine M, Gaina A, et al. Association ofsmoking behavior and socio-demographic factors,
work, lifestyle and mental health of Japanese civil
servants. J Occup Health. 2007; 49: 443-52.
23）Arima S, Yayama S, Mikami H, et al. The statusof smoking cessation support by nurses in general
hospitals, and related factors. Nippon Koshu Eisei
Zasshi. 2010; 57: 203-13.

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79日本禁煙学会雑誌

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2011 年（平成 23 年）12 月 19 日

Appendix 1
Appendix 1

Smoking Surveillance Questionnaire for the Staff ofIbaraki Prefectural Central Hospital and Cancer center
A. Questions about smoking.
We will ask you about your perception of smoking.
Please circle the reply that best reflects your opinion.
Q１. Smoking itself is a diseasea. Definitely Yes

b. Probably Yes

c. Probably No

d . Definitely No

c. Probably No

d . Definitely No

c. Probably No

d . Definitely No

c. Probably No

d . Definitely No

Q２. Smoking is a part of culturea. Definitely Yes

b. Probably Yes

Q３. Tobacco is one of life’s pleasures
a. Definitely Yes

b. Probably Yes

Q４. Smokers’ lifestyles may be respected
a. Definitely Yes

b. Probably Yes

Q５. Smoking sometimes enriches people’s lives
a. Definitely Yes

b. Probably Yes

c. Probably No

d . Definitely No

Q６. Tobacco has positive physical or mental effects
a. Definitely Yes

b. Probably Yes

c. Probably No

d . Definitely No

c. Probably No

d . Definitely No

Q７. Tobacco has effects to relieve stressa. Definitely Yes

b. Probably Yes

Q８. Tobacco enhances the function of smokers’ brains
a. Definitely Yes

b. Probably Yes

c. Probably No

d . Definitely No

Q９. Doctors exaggerate the ill effects of smoking
a. Definitely Yes

b. Probably Yes

c. Probably No, d . Definitely No

Q 10. People can smoke at places where ashtrays are available
a. Definitely Yes

b. Probably Yes

c. Probably No

d . Definitely No

The questionnaire continues
1

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日本禁煙学会雑誌

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2011 年（平成 23 年）12 月 19 日

B. Questions about smoking status.
Please answer all in the question on the following Q1-10. Moreover, please answer Q11 and 12, Q13 and 14, and Q15 and 16 for the
doctors, the nurses, and the pharmacists respectively. Time necessary for filling in is about five minutes.
Q１. What is your gender?

1. FemaleQ２. What is your age?

1. 20’s

2. Male2. 30’s

3. 40’s

4. 50’s

5. 60’s or more

Q３. What is your employment category in this hospital?
1. Full-time

2. Part-time

3. Other (On assignment, Contract worker）

Q４. Do you do the business for facing to the patient?

1. Yes

2. No

Q５. Do you advise patients directly in your profession?

1. Yes

2. No

Q６ What is your profession?
1. Medical Doctor

2. Nurse, Midwife, Public health nurse

4. Laboratory medical technologist
7. Occupational therapist

3. Pharmacist

5. Radiology technician

8. Speech language pathologist

10. Other medical profession in hospital

6. Physical therapist

9. Dietitian

11. Clerical or site maintenance worker

Q７．How long have you worked in this hospital?
1. <2 yr
2. 3–5 yr
3. 6–10 yr
4. 11 yr +Q８．Do you smoke cigarettes?
1. I have never smoked or only smoked a few cigarette in my entire life
2.

I smoked cigarettes but I have stopped smoking for more than one month3.

I smoke cigarettes every day
How many cigarettes do you smoke?

() / day

During the next 6 months, do you want to quit smoking?
Do you want support to quit smoking in the hospital?

1. Yes
1. Yes

2. No
2. No

What kind of support do you want to quit smoking?
1. Counseling
2. Provision of nicotine gum or nicotine patch
3. Introduction to cessation clinics
4. Information about smoking cessation

2

Smoking status and KTSND
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2011 年（平成 23 年）12 月 19 日

Q９. Do you have any opinion or proposal for the prohibition of smoking in this hospital at his time (August, 2006) and fill it
in freely, please.

Q 10. Second-hand smoke (breathing in smoke of others' cigarettes) may cause events such as cardiac infarction, cancer, andasthma, and even a small amount is harmful.
Are you exposed to second-hand smoke in every day life?
If ‘Yes’, where are you exposed to second-hand smoke?
5. Station

6. Car

7. Restaurant

7. Bar or tavern

1. Yes
1. Home2. No.
2. Office8. Karaoke

3. School

9. Pachinko

4. Public office

10. Others

We ask only doctors, nurses, and pharmacists the following questions.
For the others the questions end here. Thank you for your cooperation.

For doctors, please answer Q 11 and Q 12.
Q 11. Do you know the smoking cessation guideline issued by nine societies including the Japanese Circulation Society?
1. Yes
2. No.
If you answered Yes above, have you ever read at least a part of the guideline?
1. Yes
2. No.
Q 12. If your patient is a smoker, what is your practice concerning smoking cessation?
1. I direct almost all patients to quit smoking
2. I direct more than half of patients to quit smoking
3. I direct about half of patients to quit smoking
4. I direct less than half of patients to quit smoking
5. I do not direct patients to quit smoking but take the opportunity to give some advice
6. I do not direct patients to quit smoking because there is no chance to give advice in my job
For nurses, please answer Q 13 and Q 14.

3

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2011 年（平成 23 年）12 月 19 日

Q 13. The Japanese Nursing Association made action plans against smoking for nursing professionals in March, 2004. The action planconsists of two parts; the action plans against smoking, and guidance of support to quit smoking.
Do you know this action plan for nurses made by Japanese Nursing Association?
1. Yes
2. No.
If you answered Yes above, have you ever read at least a part of the action plans?
1. Yes
2. No.
Q 14. If your patient is a smoker, what is your practice concerning smoking cessation?
1. I direct almost all patients to quit smoking
2. I direct more than half of patients to quit smoking
3. I direct about half of patients to quit smoking
4. I direct less than half of patients to quit smoking
5. I do not direct patients to quit smoking but take the opportunity to give some advice
6. I do not direct patients to quit smoking because there is no chance to give advice in my job

For pharmacists, please answer Q 15 and Q 16.
Q 15. The Japanese Society of Hospital Pharmacists made a declaration to promote anti-smoking measures in December, 2007 torecognize that it was an obligation to promote measures against smoking and to support smoking cessation as professionals who protect
public health.

Do you know this declaration by the Japanese Society of Hospital Pharmacists?
1. Yes
2. No.
If you answered Yes above, have you ever read at least a part of the declaration?
1. Yes
2. No.
Q 16. If your patient is a smoker, what is your practice concerning smoking cessation?
1. I direct almost all patients to quit smoking
2. I direct more than half of patients to quit smoking
3. I direct about half of patients to quit smoking
4. I direct less than half of patients to quit smoking
5. I do not direct patients to quit smoking but take the opportunity to give some advice
6. I do not direct patients to quit smoking because there is no chance to give advice in my job

End of all questions. Thank you for your cooperation.
Please submit it to the collection bag.

4

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2011 年（平成 23 年）12 月 19 日

Appendix
Appendix 2 2The Kano Test for Social Nicotine Dependence (KTSND): Scores
Definitely

Probably

Probably

Definitely

Yes

Yes

No

No

Q1

Smoking itself is a disease

0

1

2

3

Q2

Smoking is a part of culture

3

2

1

0

Q3

Tobacco is one of life’s pleasures

3

2

1

0

Q4

Smokers’ lifestyles may be respected

3

2

1

0

Q5

Smoking sometimes enriches people’s lives

3

2

1

0

Q6

Tobacco has positive physical or mental effects

3

2

1

0

Q7

Tobacco has effects to relieve stress

3

2

1

0

Q8

Tobacco enhances the function of smokers’ brains

3

2

1

0

Q9

Doctors exaggerate the ill effects of smoking

3

2

1

0

Q 10 People can smoke at places where ashtrays are

3

2

1

0

available
The maximum score is 30 points, and the minimum is zero.

地域がんセンター職員の喫煙状況と喫煙に関する意識調査（加濃式社会的ニコチン依存度調査票を用いて）

天貝賢二 1, 2, 11 、中村好一 2 、吉井千春 3, 11 、加濃正人 4, 11 、稲垣幸司 5, 11 、北田雅子 6, 11
大谷哲也 7, 11 、原田正平 7, 11 、栗岡成人 8, 11 、田中政宏 9, 11 、田中英夫 10
茨城県立中央病院消化器内科 、2．自治医科大学公衆衛生学部門 、3．産業医科大学呼吸器内科
4．
新中川病院 、5．愛知学院大学短期大学部歯科衛生学科 、6．札幌学院大学経営学部
7．
国立成育医療研究センター、8．城北病院 、9．大阪府立成人病センターがん予防情報センター1．

愛知県がんセンター研究所疫学・予防部 、11．禁煙心理学研究会

10．

【目 的】 今回我々は 、病院職員の喫煙状況と合わせて喫煙に関する意識を加濃式社会的ニコチン依存度調
査票（KTSND）を用いて調査した。
【方 法】 地域がんセンターを併設する病院の職員に喫煙状況や禁煙支援の頻度等とともに KTSND を含む
自記式調査表を配布し 、611 名の有効回答を得て解析した。
【結 果】 喫煙率は医師 5.4 ％、看護師 17.4 ％、他の医療職 3.9 ％、事務・現業職 21.9 ％であった。KTSND
得点（平均値 ±SD）は非喫煙者 11.0±5.9 、前喫煙者 12.2±4.7 、喫煙者 14.7±4.4 で喫煙者では有意に高かった。
職種別では非喫煙者では有意差を認めないが 、喫煙経験者（前喫煙者 + 喫煙者）では医師 12.3±6.2 、看護師
13.7±5.0 、他の医療職 15.7±4.6 、事務・現業職 17.2±5.4 であり 、医師や看護師と比較して事務・現業職で有意に高値であった。
【結 論】 地域がんセンターを有するような病院では職員の喫煙率が低いことが期待されたが 、実際の喫煙率はさほど低くなかった。また 、職員の KTSND 得点は喫煙状況や職種によっても差が見られた。禁煙推進のためには灰皿をなくし病院を敷地内禁煙にすることが必要である。
キーワード：加濃式社会的ニコチン依存度調査票（KTSND）、喫煙 、ニコチン依存 、病院職員

連絡先〒 309-1793
茨城県笠間市鯉淵 6528
茨城県立中央病院 消化器内科

天貝賢二

TEL: 0296-77-1121 FAX: 0296-77-2886
e-mail: k-amagai@chubyoin.pref.ibaraki.jp
受付日 2011 年 1 月 4 日 採用日 2011 年 10 月 14 日

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